| Our policies are used as guidelines
for coverage determinations in all health care insurance
products, unless otherwise indicated. Benefit determinations
are based on applicable member contract language. Plan
language will be followed if there are any conflicts
between these Policies and the Plan.
Newly established or revised medical, reimbursement
and administrative policies and information on quality
improvement activities may be communicated in our newsletter, The
Connection OnlineSM, or by letter.
It is important that physicians, other health care
professionals, facilities and their staff review each
issue to keep abreast of these policies.
Provider Incentive Plans
Any provider incentive plans established by Asuris
shall be designed to improve the quality and efficiency
of health care provided to its members.
If a provider incentive plan is based on the utilization
of health care services, the plan must contain mechanisms
to ensure that members are receiving medically necessary
health care. Such mechanisms may include, but are not
limited to:
- audits of case files
- overall assessment of causes of utilization pattern
variation, and
- offsetting financial incentives that relate to
quality
For more information about specific policies, select
the appropriate manual:
| Medical
Policy |
The purpose of medical policy
is to provide guidelines for determining coverage
criteria for specific procedures, equipment
and services. The Introduction section of this
manual includes information about:
- Selecting Technologies
- Research Sources
- Technology Assessment
- Approval process
NOTE: Asuris Medical Policy
does not apply to Medicare and Asuris TruAdvantage™.
Review the Medicare
Advantage Plans (PDF) section for
more information. |
| Behavioral
Health Policy |
These policies are developed using
evidence-based treatment guidelines as well as
clinical best practices/standards of care. They
are consistent with Milliman, Substance Abuse
and Mental Health Services Administration (SAMHSA)
and culturally competent practice philosophy
and standards. |
| Reimbursement
Policy |
These policies document Asuris
payment policy and correct coding for medical
and surgical services and supplies. |
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